JAMA Forum: Why Is US Maternal Mortality Rising?

In the first 15 years of this century, the rate of maternal mortality around the world decreased by more than a third. Shockingly, rates in the United States have been rising.

In 2005, 23 US mothers per 100 000 live births died from complications related to pregnancy or childbirth. In 2015, that number rose to 25. In the United Kingdom, the number was less than 9. In Canada, it was less than 7.

Very few wealthy countries saw increases over those years. Many poorer countries, including Iran and Romania, saw declines. But here in the United States, things got worse.

These numbers have been confirmed by independent research. Last year, a study published in Obstetrics and Gynecology found that the maternal mortality rate in the United States had increased by more than 25% from 2000 to 2014. This trend differed by state, however. Although California had shown some declines, Texas had seen significant increases.

Texas in particular has been the focus of much of the news on maternal mortality in the last few years. From 2011 to 2014, the rate doubled. Although we lack good data to tell us why, many have postulated that changes to family planning in the state coincided with this increase. In 2013, for example about half of the state’s clinics that provided abortion in addition to other reproductive health services were closed because of regulations passed against them. In 2011, the family-planning budget was slashed in an attempt to defund Planned Parenthood. Many clinics closed and more were forced to reduce their services.

Family planning matters. About 50% of pregnancies in the United States are unplanned and might lack preventive care that properly planned-for pregnancies might.

There’s more to this story than changes in regulations and family planning. Some of the increase is likely due to the growing prevalence of other chronic conditions. Obesity, diabetes, and heart disease likely contribute to maternal mortality, and trends for many conditions have been increasing over the last decade. Women are having children later in life than they used to, and some have more complex conditions. More women have caesarian deliveries, which can lead to complications. The opioid epidemic may contribute to maternal mortality, as well.

Disparities exist in maternal mortality as they do in other areas of health care. The increases we’ve seen are most noticeable in non-Hispanic black women. The number of deaths per 100 000 live births among black women is more than 3 times that among white women. In fact, for any state, the higher the percentage of black women in the delivery population, the higher its rates of maternal mortality. But racial disparities can only account for so much of the problem. Even if you look only at white women in the United States, the rates of mothers who die is greater than those in other developed countries.

The fragmented nature of the US health care system doesn’t help either. Too many people in the United States go without necessary care, because they lack access to care or avoid it because of cost. This is just as true of pregnant women as it is of everyone else. As many politicians argue that maternity care shouldn’t be considered essential benefits, some worry that coverage might get worse with reform.

It is possible that some of the increase in maternal mortality is due to better record keeping. States have been working to improve how they keep track of maternal deaths, as well as other causes of death, and better reporting would be reflected as increases in prevalence. It’s hard to imagine, however, that this increase in better records has been solely in the United States, and could account for all of the increases. There’s no reason to believe that all other countries would be keeping themselves in the dark. Moreover, the more universal and socialized health systems are less likely to have women, and their deaths, fall through the cracks and be missed.

Pregnancy and childbirth are risky. We don’t like to talk about it, but maternal mortality is the sixth most common cause of death among US women age 25 years to 34 years old. Proper maternal care helps to prevent morbidity and mortality, but that care is difficult when clinics close and insurance lapses. Medicaid can help to close the gap and often does with pregnant women, but even then, both physician services and mother’s finances are strained.

As with many things in health care, a rising tide would lift all boats. Efforts to improve the health of women in general would improve our rates of maternal mortality. Reducing levels of obesity, diabetes, and heart disease would achieve results. So would getting a handle on the opioid epidemic. But we’ve spent the last few years—if not more—focused on efforts to reduce infant mortality. Mothers may need a similar commitment.

About The JAMA Forum:JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.